Collaborative Care for Depression and Posttraumatic Stress Disorder: Evaluation of Collaborative Care Fidelity on Symptom Trajectories and Outcomes

Abstract

Background: Despite the growing consensus that collaborative care is effective, limited research has focused on the importance of collaborative care fidelity as it relates to mental health clinical outcomes.

Objective: To assess the relationship of collaborative care fidelity on symptom trajectories and clinical outcomes among military service members enrolled in a multi-site randomized controlled trial for the treatment of depression and posttraumatic stress disorder (PTSD).

Design: Study data for our analyses came from a two-parallel arm randomized trial that evaluated the effectiveness of a centralized collaborative care model compared to the existing collaborative care model for the treatment of PTSD and depression. All patients were included in the analyses to evaluate how longitudinal trajectories of PTSD and depression scores differed across various collaborative care fidelity groupings.

Participants: A total of 666 US Military Service members screening positive for probable PTSD or depression through primary care.

Main measures: Disease registry data from a web-based clinical management support tool was used to measure collaborative care fidelity for patients enrolled in the trial. Participant depression and PTSD symptoms were collected independently from research survey assessments at four time points across the 1-year trial period. Treatment utilization records were acquired from the Military Health System administrative records to determine mental health service use.

Key results: Consistent and late fidelity to the collaborative care model predicted an improving symptom trajectory over the course of treatment. This effect was more pronounced for patients with depression than for patients with PTSD.

Conclusions: Long-term fidelity to key collaborative care elements throughout care episodes may improve depression outcomes, particularly for patients with elevated symptoms. More controlled research is needed to further understand the influence of collaborative care fidelity on clinical outcomes.

Trial registration: Clinicaltrials.gov Identifier NCT01492348.

Keywords: collaborative care; depression; posttraumatic stress disorder; treatment fidelity.

Conflict of interest statement

Compliance with Ethical Standards

The study was reviewed and approved by institutional review boards at Walter Reed National Military Medical Center, six participating Army installations, RTI International, RAND Corporation, University of Washington, the Boston VA, and the Human Research Protection Office, US Army Medical Research and Materiel Command. Written informed consent was obtained after full explanation of study procedures.

Conflict of Interest

The authors declare that they do not have a conflict of interest.

Figures

Figure 1

Longitudinal clinical trajectories of depression severity (HSCL†) for 4 collaborative care management (CoCM) fidelity groups (N = 666). †HSCL: Hopkins Symptom Checklist Depression Scale-20 Item Version. • Low Fidelity: less than 2 months of collaborative care management services in the first and last 6 months of care. • Early Fidelity: two or more months of collaborative care management services in the first six, but not last 6 months of care. • Late Fidelity: two or more months of collaborative care management services in the last six, but not first 6 months of care. • High Fidelity: two or more months of collaborative care management services in the first and last 6 months of care.

Figure 2

Longitudinal clinical trajectories of PTSD severity (PDS†) for 4 collaborative care management (CoCM) fidelity groups (N = 666). †PDS: Posttraumatic Diagnostic Scale. • Low Fidelity: less than 2 months of collaborative care management services in the first and last 6 months of care. • Early Fidelity: two or more months of collaborative care management services in the first six, but not last 6 months of care. • Late Fidelity: two or more months of collaborative care management services in the last six, but not first 6 months of care. • High Fidelity: two or more months of collaborative care management services in the first and last 6 months of care.